November Log

Seizure

I was dispatched for a CVA. I found an 80 year old woman at an adult day care center who had what sounded like a seizure/possibly hemoragic CVA. Facial twitching, staring off to one side, but was back to normal now possibly. Her daughter showed up and I asked the daughter to look at the mother and tell me if this was normal. I turned around and the mother was seizing again. Not normal. We quickly loaded her into the back of the ambulance, and I immediately put her on the capnography, and then quickly got an IV line, and got the ativan out. On the capnography it looked like she went apneic for about thirty-firty seconds, enough to set the apnea alarm off, and then I could see she was breathing and her ETCO2 was up to 50-60. Then just before I could give her the ativan, she stopped seizing. I tried to run a trend summary, but the monitor I had didn't have the trend software turned on. I quickly got into the code and turned it on, hoping if she had another seizure I could capture what I had witnessed.

She started seizing again, but I didn't see the apnea. I waited a little bit, and then was feeling this conflict between the clinician and the scientist. I wanted to hold off so I could get a good strip showing apnea, and then hypoventilation, but on the other hand, I did have a job to do. So I gave her the ativan. That stopped most of the shaking except for the facial twitching.

Hyperventilation

I was called for chest pain and found a fifty year old woman screaming she couldn't breath and her chest hurt. Her family denied any medical history. I thought she was hyperventilating. I put her on the capnography.

ETCO2-17 RR-56

I tried to get her to concentrate on the monitor, on bringing up the ETCO2 number and bringing down the RR number. That lasted about ninety seconds and then she was again screaming that she couldn't breathe. I checked her out from head to toe. Everything fine. I asked her husband again if she had any medical problems or took any meds or used to, and he just shook his head. On the way to the hospital,while I was on the phone with the doctor asking for orders for ativan to sedate her, in between screaming episodes she let it slip that she didn't want to go to the "purple pod' which is where the psychs go. That told me all I needed to know. The ativan worked wonders. I gave her 1 mg and then a second when she was still agitated, and that did the trick. She really mellowed out.

Here's her strip on arrival at the hospital.

ETCO2-35 RR-17

But then when the triage nurse told her she had to go to the purple pod, despite the ativan, she went back into having a fit, including tearing the capnography cannula out of her nose. "People will here about this!" she screamed. "I am not happy!"

Nasotracheal Intubation

The morning after writing Capnography and Intubation about using capnography to aid intubation, my first call ended up being an intubation in which I used capnography to help intubate.

The call was for unresponsive patient with severe dsypnea. We found an 80 year old female with a GSC of 4-5 breathing at a rate of 60 with cool extremities. Unable to hear BP. Heart rate on the monitor 130-140. Blood sugar - 213. I attached the capnography filter to the end of the ET tube. Some of our ET tubes come with stylets already in them. I removed the stylet, but could not put it back in because it was to thick, so I used a thinner stylet. I went in, and had a hard time getting the woman's jaw open enough to see the chords. We don't have RSI so there was what we call inadequate relaxation. I could just barely see the chords under the epiglottis, but couldn't get the tube to pass through. Instead of checking by assessing breath sounds, I just looked at the monitor. The ETCO2 would just go straight and I'd know I had gone below the chords. I ended up nasally intubating her, which I probably should have done first, but I like to get a bigger tube in. The nasal tube went in great. I used a 6.0 and watched the wave forms as I fed it. The form went down to nothing, I pulled back and repositioned her head and then advanced the tube again, and felt it go through and had the big wave forms to confirm it.

Her SAT went up to 98% from the 80% and her ETCO2 came up from the mid twenties to low to mid thirties. She opened her eyes by the time we were in the ED.

I'm still waiting to hear what was wrong with her - most likely sepsis.

Hypoventilation not Hyperventilation

We were called for an OD, unconcious, but when we got there we found a 32-year-old extensively tattooed woman standing, looking slightly dazed, saying she was having trouble breathing and just needed an inhaler. I listened to her lungs (in the lower lobes) and they were clear, which I announced to the assembled room of five firefighters, my partner, two cops, and three bystanders. Then with the next breath, she coughed and sounded very rhoncorus to the naked ear. "She doesn't sound clear," one of the bystanders said like I was an idiot. "She's talking fine," I said, "using complete sentences." Then I asked the patient what hospital she wanted to go to. She said she didn't want to go, she just wanted a treatment. I said, we don't do home treatments, if she was having trouble breathing we needed to take her to the hospital. Now in the meantime, I am hearing one of the bystanders explain to my partner that someone had found her unresponsive in the bathroom with blood all over the floor and walls that she either vomited or coughed up. I looked in the bathroom, only to see a woman just finishing cleaning it all up. The patient still just wanted a treament, but with the help of the cops, we insited she go with us. I helped her walk down one flight of narrow stairs down to where we had the strethcer. She wanted to walk to the ambulance -- at the same time she was begging with me to give her a treatment. We had her lay on the stretcher and I set the back up straight. Out in the ambulance, I put her on the pulse ox, and while her fingers were cold -- it was a wet, raw day, the pulse ox read less than 50, and then got up to 70. She was really sort of panicking now, and I listened again to her lungs - this time to the upper lobes and oh, my -- they were coarse and rhonocous and nasty. I put her on the capnography thinking that I would see low numbers, and this is what I had. ETCO2 - 70!

She got more and more panicky as I gave her a treatment by mask and had my partner drive lights and sirens the three blocks to the hospital, where we raced her in. The triage nurse and the other crew waiting in line looked at me maybe like I was crazy as I insisted we cut in front and that my patient was in true distress and not just your typical anxiety attack. I had to explain about the capnography -- why she wasn't hyperventilating and how I though maybe she has aspirated. They sent us down to a priority room, where I got the same looks and had to again explain that this wasn't what it first looked like. The doctor listened to her lungs -- lower lobes -- while a nurse coaxed her to slow her breathing down, and I had to have them listen to the upper lobes and show them they she was in fact hypoventiliating.

It didn't take them long to understand and see she was hypoxic. She then coughed up some blood and then admitted she had done two bags of heroin. I will try to check back to find out the final story, but the respiratory therapist agreed he thought she probably had aspirated.

The bottom line for me was while I was at first poo-pooing her complaint -- she appeared after all the typical junkie whiny borderline asthmatic anxiety type with a chest cold, the capnography slapped me in the face to what maybe I should have been seeing all along. It screamed out -- she is having a big problem!

I gave her a treament, which didn't seem to help her too much, although her ETCO2 number did come down into the high 50s. Her respiratory rate also picked up, which may have driven the number down some.

Just why the number was elevated, there are a number of possibilities. She had possibly been apneic before being found, her tachycardia -- 136 -- increased cardiac output drove the C02 number up, the aspiration tired her and limited air movement.

I'll update if I get any more information.

Respiratory Distress

I intubated an 80 year old woman in a nursing home who was breathing agonally (gasping like a fish) and had no palpable pulse or ausculable BP. Of course the nursing home had her on a mask at 4 lpm, and when I told the nurse to take her off it and start bagging her -- at least they had an ambu-bag out, she put the ambu bag on her like it was a face mask and just left it there. No, you have to squeeze the bag! I said. The patient was very cool and clammy.

I first put on the capnography cannula while my partner stepped in and started bagging her. Her ETCO2 was 24. I intubated her easily, and, as always, was glad to see the wave forms on the monitor.

Note: The bumps in the 2nd and 3rd wave forms are her efforts to breathe. The arrows at the bottom are indications of her pacemaker firing.

While I still couldn't get a pulse or BP, I knew from the ETCO2, she at least had some cardiac output. She stayed about the same all the way to the hospital. I couldn't get an IV in, so I didn't do much more than assist her breathing. At the hospital, she finally opened her eyes.

I kept her on our capnography until the hospital could find theirs. They just got one, and all it records is the capnometer, not the wave form.

I know the AHA recommends that you do all the checks to make certain, your ET tube is in, but with capnography, I tend to skip certain checks such as using the bulb syringe, and I may delay the lung sounds. If I see the tube pass, I have a wave form, and I have mist in the tube, with a breathing patient, I don't really think the bulb syringe is neccessary. In a potentially fast moving scene, such as an imminent arrest(which this looked like at first, but turned out not to be)maybe the capnography is good enough.

In this call I didn't check the lungs and belly for several minutes. At the hospital we are required to have the ED doctor verify our tube by listening to the lungs and belly. I wasn't concerned because I have the capnography going right there, and the trend summary showing a constant ETCO2. She checked them and signed the sheet for me.

Postscript: Thinking about this later, you still need to check lung sounds to make certain you haven't intubated the right mainstem.

Stroke patient

70 year old male with left sided weakness, nonverbal, gazing to the left. His ETCO2 started out at 23 and slowly went down to 17. I couldn't really figure it out. He was tackycardiac, and his pressure was 110/50. His respiratory rate increased slightly from 20 to 24. I don't know whether the low ETCO2 was due to a poor reading, hyperventilation, or declining cardiac output or saliva on the mouth part of the capnography line. I am going to try to follow up to see what happened to him in the ED after we left. Many capnography stories are picture clear, others like this one leave me puzzled.

?Pneumonia/CHF

Had a 65 year-old female with increasing shortness of breath on exertion. Some CHF history. Pedal edema. Her lung sounds were decreased in the lower left lobe. She appeared in no distress sitting, but quickly became short of breath on standing and pivoting into our stair chair. Big heavy woman. Three floor carry-down. (Whine Whine). Her vitals were fine. Sat 97% on a couple liters. I eye-balled her respiratory rate at 20. I wasn't going to put her on the capnography. I'm trying to only use it now when I really need it as opposed just general experimentation -- I don't want to depelete our supply. Then just as we neared the hospital, I eyed her a little more closely and she did seem to be slightly short of breath, although she denied it. I put her on the capnography and got the strip below.

I was startled to see her respiratory rate was 40, and stayed there. Her ETCO2 was low due to the hyperventilation. I guess it just goes to show, you can't eye-ball a respiratory rate and expect to be accurate. At the triage desk, I waited for the triage nurse to eyeball the respiratory rate. She wrote down 24. I then told her I was getting 40. Whether or not, that higher rate made a difference in the order of care she got in the crowded ED, I don't know, but maybe.

For those who missed it, here's the classic waiting room computer shot that appeared in the Annals of Emergency Medicine about synpnea -- where everyone in the waiting room gravitates toward the same respiratoty rate:

Vomiting COPDer

Called for dsypnea. Found an 80 year old female with a respiratory rate of 34, a fever of 101, and ETCO2 of 34, and an upright capnograph. Her lungs were decreased. No wheezing. I upped her 02 from 2 to 4 on the capnography dual cannula to get her SAT from 89 to 94. The only problem with the capnography cannula was she vomitted, and splashed the mouth flap, so I had to clean it, and then everytime, she puked, I had to move it out of the way, basically taking her off 02.

Unresponsive

We get called to a nursing home for an unresponsive patient. A 55 year old male IDDM with a big psych history, who was recently discharged from psych hospital on heavy duty meds. His blood sugar is 220. Pupils midsized. BP 120/70, HR - 84. Skin warm and dry. Does not respond to sternal rub. Does not respond to IV. Only semi-response we get is from moving him from bed to stretcher on draw sheet.

Capnography shows ETCO2 is 35. RR is 12.

Monitor him all the way in. Capnography and RR remains constant.

My guess is he is over medicated. At the hospital they ask if we gave narcan. I say no because his respirations are 12, his pupils non-constricted and the capnography shows he is ventilating noramally.

I like the use of capnography here just to get a quick picture off the back whether he is having a problem or not. Someone else might try to intubate him due to his GCS in the 7-9 region. For me the capnography shows no ventilation problem, his airway appears patent. We just monitored him on the way in.

Infant

We got called or an infant, whose mother said he had stopped breathing for about two minutes, and just wasn't right. The two week old seemed okay to me. Out of curiousity, I tried to put a capnography cannula on him, but he was too little. No matter how I positioned it, I couldn't get a reading.

4 Comments:

Regarding the bulb syringe as a secondary confirmation device. It's is a very good test, in terms of its specificity, as to detecting a tube placed in the esophagus. It does have some problems with improperly detecting well-placed tubes -- false negatives.

But anyway, I'm with you on the skipping of it. In the OR, the CRNA looks for a good wave on the capnography, the ologist looks for chest rise and bilateral breath sounds, and everyone looks at patient condition and o2 sats.

One of the anestheologists told me not to worry about a false reading of expired CO2 from the stomach because it's gone after a few puffs. I take that to mean that the capnography does its job.

I really liked the bulb syring when it first came out. I found it useful to tell me I was in the esophagus. If I had a difficult intubation and i wasn't certain I was in, if the bulb didn't reinflate, I yanked the tube immediately.

I know they teach you not to pass the tube unless you can clearly see the chords, but in practice when you need to get the tube right now, i see nothing wrong with porrping it in, and if the bulb syring says youre not in, you yank it with little time lost. I always used the bulb syringe before bagging to check lung sounds so I wouldn't be putting any air in the stomach if I wasn't in.

The problem with the bulb syringe was I had one occasion where it reinflated, but when I checked belly sounds, I was still in the esophagus. So it wasn't 100% at picking up esophageal tubes, but your other confirmations did that.

Its interesting what you write about false negatives because the experience was the opposite for me, although I can understand how that could occur.

Another caveat of the bulb syringe is the false positive: A tube in hypopharynx will reinflate.

If the tube became dislodged at any time and is now in the hypopharynx or even right at the cusp of the glottic opening now it will give a positive test for being in the correct place.

While writing this I was reminded of one of the studys you posted about an EMS system (in Florida, I believe) which eliminated "wrong hole" intubations with capnography.

Looking further in to that, how often did the capnography reveal to the medics that they were in the esophagus vs. how many times they were in the trachea on the first try and the capnography just proved it?

I think a medic "tube confidence" study might be interesting, with the medic asked if after each intubation (but prior to any primary/secondary confirmation usages) he/she was sure they were in and then comparing it to capnography result.

In an ideal world we'd like healthcare providers who place tubes correctly the first time and then have capnography as an adjunct to confirm the initial placement, provide information about the patient's condition (low etCO2 = poor outcome) and provide continuous monitoring for both legal/QA/QI CYA reasons and to monitor the patient's condition (early identifier of ROSC).

Capnography should't be used as a crutch for providers, i.e. "Well, I put the tube in, I'm not sure if its in, I didnt really see cords, but it doesn't matter, the capnography will tell and then I can yank it and try it again."

We'd consider it ridiculous for a medic or RN to blindly do an IV stick without some confidence of actually puncturing then securing the catheter inside a patent vein and then using the resulting IV filtration as the test by which they were successful or not in starting an IV.

Its an awkward comparison (since sometimes you really do think you have a patent IV, and the sudden infiltration to be the only way to know the vein popped), but I believe you can see what I'm aiming it.

Capnography should be an adjunct, a tool. Having competent medics who can be confident on passing the tube the first time should be the ideal metric for any system.

Even then though, perhaps if capnography just identifies a misplace tube and the provider realizes they can't ETI and just uses BLS manuevers or a combitube/LMA, it is better than them leaving a misplaced tube in.

I agree with you that capnography should be an adjunt, not a crutch. I also think the study you suggested about paramedic confidence (What percentage of the time you pass a tube do you feel the tube is in, prior to using any confirmation?) would be fascinating and revealing. I think there will only be a few medics claiming 100% sure for all their tubes.

The prehospital tube is often not straight forward. Sometimes the throat is filled with fluids that you can't suction fast enough, sometimes you can't bag the patient effectively, sometimes, your view is obscured so once you've started passing the tube you lose partial sight of the chords. If it were easy, we wouldn't need adjuncts. And there are sometimes when your intubation is blind -- I have a few nasal tubes, three digital tubes (I have long slender fingers which help). Since the bougie came out I have used one on four occasions (and only once missed with the bougie).

The IV analogy doesn't quite hold up (although I understand what you are getting at) because there are many times when we have patients with no visible or palpable veins, who are in extremis, and we are forced to do blind sticks based on anatomy. We judge by a blood flash.

This discussion raises an interesting and controversial question. Now that capnography so easily confirms a tube should medics be taught to abandon the never pass a tube unless you see it pass through the chords mantra, which as I've said doesn't always apply anyway. I think educators and physicains would be reluctant to abandon it, but it might at least be worth talking about.

I have read that studies are underway on a new type of ET tube that has a capnography meter on the end of it, and can be used for blind intubations on difficult airways. The rule being four continous quality waveforms indicates you are in the trachea. The patient of course would have to have respirations. You could make your own version of such a tube simply by attaching the capnography filter to the top of the ET tube(you couldn't use a stylet). This would also work for nasal tubes. You could attach a tube adapter with a 6.5 ET top attached to your starthescope so you could be listening at the same time. (I'll make a photo of this).

I may take our discussion and raise it in the main section at a later point. I am going to try to research that ET tube as well as chat with some doctors about their opinions.